Spectrum (Devon and Autistic Community Trust) East Wheal Rose Inspection report

St East Cornwall TR8 5JD Tel: 01872 510750 Date of inspection visit: 30 September 2015 Website: www.spectrumasd.org Date of publication: 04/01/2016

Ratings

Overall rating for this service Requires improvement –––

Is the service safe? Requires improvement –––

Is the service effective? Requires improvement –––

Is the service caring? Good –––

Is the service responsive? Good –––

Is the service well-led? Requires improvement –––

Overall summary

We inspected East Wheal Rose on 30 September 2015, the registered providers, they are ‘registered persons’. inspection was unannounced. The service was last Registered persons have legal responsibility for meeting inspected in January 2014, we had no concerns at that the requirements in the Health and Social Care Act 2008 time. and associated Regulations about how the service is run. East Wheal Rose provides care and accommodation for The service was sometimes under staffed. Staff told us up to two people who have autistic spectrum disorders. they did not think staffing levels had impacted people’s At the time of the inspection two people were living at the safety or resulted in any increased risk to people or staff. service. There was a registered manager in post. A They did tell us there was an impact on the opportunities registered manager is a person who has registered with for people to take part in activities in the community or the Care Quality Commission to manage the service. Like be supported with tasks at the service. 1 East Wheal Rose Inspection report 04/01/2016 Summary of findings

The people living at East Wheal Rose did not use words to Staff had access to an effective and thorough programme communicate and had complex support needs. This of training. This included training in areas specific to the meant it took time to get to know them and understand needs of the people they supported. New employees how best to support them. Staff told us that less undertook a comprehensive induction which experienced employees sometimes lacked confidence to incorporated theoretical, classroom based training and support people without the help of more experienced shadowing more experienced staff. staff. The shortage of staff numbers meant this could be Care plans were individualised and contained detailed difficult to manage. and up to date information regarding people’s support Experienced staff were confident when working with needs. Staff told us the information was relevant and easy people and knew their needs and communication styles to access. People’s routines were clearly laid out and well. A relative told us staff were consistent in the way in there was information about what was important for and which they supported their family member. There were a to people. range of communication tools available for people which Staff told us they were a close team who got on well enabled them to make day to day choices. together. They said they had worked hard to cover staff Due to people’s health needs there were restrictions in shortages and help ensure people were supported place throughout the service. The requirements of the effectively. However they reported a lack of confidence in Mental Capacity Act (2005) and associated Deprivation of the management of the service at all levels. Staff did not Liberty Safeguards (DoLS) had been adhered to. This feel their grievances were always listened to and told us meant people’s legal rights were protected when their they did not have confidence in a recent consultation liberty was restricted. Staff worked to help ensure people process. Where concerns had been raised they felt these were supported to access the community and take part in had not been adequately listened to. activities they enjoyed when staffing levels permitted this. Regular audits were carried out to help ensure the service Strategies to support people to have as much autonomy was safe. Incidents and accidents were recorded as possible were developed. appropriately and analysed monthly in order to highlight The provider had identified where changes to the any trends. People’s views regarding the running of the environment were necessary to meet people’s needs. service were actively sought out. However, action had not been taken to meet those We found breaches of the Health and Social Care Act 2008 identified needs in a timely manner. For example a (Regulated Activities) Regulations 2014. You can see what bathroom was in need of refurbishment; although this action we have told the provider to take at the end of the had been highlighted by the provider in 2014 the work full version of the report. had not been completed.

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The five questions we ask about services and what we found

We always ask the following five questions of services.

Is the service safe? Requires improvement ––– The service was not entirely safe. Low staffing levels meant people were not always able to take part in activities outside the service. People were protected from abuse because staff had received safeguarding training and were confident about reporting any concerns. Staff were knowledgeable about what actions to take to reassure people if they become anxious or distressed.

Is the service effective? Requires improvement ––– The service was not entirely effective. Action was not always taken in a timely manner to meet people’s identified needs. Staff received relevant training to help ensure they could support people well. The service met the requirements of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards. This helped to ensure people’s rights were respected

Is the service caring? Good ––– The service was caring. There was a range of communication aids available for people. Staff spoke about people with affection and were knowledgeable about their needs. People were supported to maintain relationships which were important to them

Is the service responsive? Good ––– The service was responsive. Care plans were detailed and informative. The staff team communicated well with each other to help ensure they were up to date with people’s changing needs. People had access to a range of meaningful and enjoyable activities.

Is the service well-led? Requires improvement ––– The service was not well-led. Due to staff concerns regarding staffing provided, the management of the service, and about Spectrum generally, staff morale was low. Staff demonstrated a shared set of values which focused on giving people choice in their day to day life. The service sought out the views of people and their families.

3 East Wheal Rose Inspection report 04/01/2016 East Wheal Rose Detailed findings

Before the inspection we reviewed previous inspection Background to this inspection reports and other information we held about the home including any notifications. A notification is information We carried out this inspection under Section 60 of the about important events which the service is required to Health and Social Care Act 2008 as part of our regulatory send us by law. functions. This inspection was planned to check whether the provider is meeting the legal requirements and Due to people’s health care needs we were not able to regulations associated with the Health and Social Care Act verbally communicate with people who lived at the service 2008, to look at the overall quality of the service, and to in order to find out their experience of the care and support provide a rating for the service under the Care Act 2014. they received. We spoke with the registered manager, the Divisional Manager with oversight of the service and five This inspection took place on 30 September 2015 and was care workers. Following the inspection we contacted a unannounced. The inspection was carried out by one relative to hear their views of the service. inspector. We looked at detailed care records for two individuals, three staff files and other records relating to the running of the service.

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Is the service safe?

Spectrum had an on-call system in place to allow staff to Our findings access a manager at all times for support if necessary. This included if they needed support to cover shifts. However Before the inspection we had received a concern that staffing across Spectrum was low and a member of staff staffing levels at East Wheal Rose were below those told us; “On-call can’t really do anything about it.” identified as necessary to meet people’s needs. The registered manager told us there was a vacancy on the staff Although staff did not believe people had been put at risk team and another staff member was due to leave to take due to low staffing numbers some did voice concerns up a position at another service in the near future. This about the need to arrange the rota to ensure experienced would create a further vacancy. On the day of the staff were always working with those with less experience. inspection a new employee had started work at the service. They told us the needs of the people they supported were The registered manager and staff confirmed that the extremely complex and it took a long time to get to know service had run below the minimum staffing levels at times. them. As both people were non-verbal staff relied on a In response to our concerns, which we had raised with the background knowledge and understanding of their Spectrum senior management team before the inspection, non-verbal communication in order to support them the divisional manager and registered manager had effectively. Staff told us that while the induction and analysed information regarding any incidents that had shadowing period was valuable it was not sufficient on its occurred. They had identified seven dates in August 2015 own to give new staff the confidence and knowledge when the service was below the agreed staffing levels as necessary to support people. One member of staff assessed as necessary by commissioners to meet people’s commented; “It’s a young team. Sometimes inexperienced needs. They compared the dates with occasions when staff are left to support people and they have little people’s anxieties had resulted in them becoming confidence.” Another said; “It’s pressure for staff. It can be distressed. They did not find any correlation between these daunting.” two factors. Staff told us they did not think staffing levels This was in breach of Regulation 18 of the Health and had impacted on people’s safety or resulted in any Social Care Act 2008 (Regulated Activities) Regulations increased risk to people or staff. They did tell us there was 2014. an impact on the opportunities for people to take part in activities in the community or be supported with tasks at Before the inspection we met with members of Spectrum’s the service. On the day of the inspection there was senior management team. They told us they had a group of sufficient staff on duty to support people. Both people new employees going through the induction process. They were supported to go out during the day on separate said this new intake would result in Spectrum being fully activities. staffed. They added that they would continue to actively recruit care workers in order to help ensure they remained We looked at rotas and other records to establish how fully staffed. The new employees had not yet been assigned many members of staff had been working during weekends to named services so we could not establish if East Wheal in September. In order to meet identified needs there Rose would have a complete staff team in the near future. should have been five people on shift for the majority of the day dropping to four at either end of the day. There People were protected from the risk of abuse because staff should have been three members of sleep-in staff on duty had received training to help them identify possible signs of each night. We found that of the eight days we looked at, abuse and knew what action they should take. Staff told us on one occasion there were five members of staff on duty if they had any concerns they would report them to the during the day. On three and a half days there were four registered manager and were confident they would be members of staff on duty, although this dropped to three followed up appropriately. They were aware of the one evening. On three and a half of the days there were management hierarchy and how they would escalate only three members of staff working. On two occasions concerns if necessary. If they were not satisfied their there were only two sleep-in members of staff on duty. The concerns were being dealt with appropriately they would registered manager confirmed to us that; “Weekends have raise them with the Care Quality Commission. Staff told us been a problem.” they believed senior management would respond appropriately to any concerns they had regarding people’s

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Is the service safe? safety. Notice boards in the office displayed details of the risk assessments staff told us they continually risk assessed local authority safeguarding teams and the action to take situations, especially when supporting people to access the when abuse was suspected. The registered manager community. They described a specific example of a trip out described a situation to us where a member of staff had and the strategies and precautions they had taken during reacted verbally inappropriately when they had been in a the trip to minimise any risks. They told us; “He did situation they found difficult. The member of staff had brilliantly, it was a real success.” received additional training and been moved to a service People’s medicines were stored securely in a locked with fewer challenges. This demonstrated action was taken cabinet in the administration office. Medicines to help ensure people were protected from possible abuse. Administration Records (MAR) were completed Some people could become anxious or distressed which appropriately. We checked the number of medicines in could lead to behaviour staff might find difficult to manage. stock for one person against the number recorded on the Care plans clearly outlined the processes to follow in this MAR and saw these tallied. One person was receiving covert situation and pinpointed when staff interventions should medicine; this is medicine which is given to people without increase in line with the level of behaviour. They identified their knowledge, for example hidden in food. There was situations which might cause anxiety for the person and evidence to show the correct legal processes had been how to avoid these where possible. There was guidance for adhered to when taking this decision with the involvement what actions to take to reassure people if they did become of a GP and family. Staff were all able to administer anxious, and descriptions of verbal and distraction medicines and had received the appropriate training. strategies to adopt in the event their reassurances were People’s money was kept securely. Records for each unsuccessful. This meant there was a clear process for staff individual were kept detailing money received and spent to follow which would help ensure a consistent approach. along with any receipts. These records were monitored by Care plans also included guidance for staff on how to the registered manager and audited monthly by reassure people following any incident. Spectrum’s finance team. We reviewed one person’s Care plans contained detailed information to guide staff as accounts and found all transactions and money held to the actions to take to help minimise any identified risks tallied. to people. The information was contained within the Recruitment processes were robust; all appropriate relevant section of the plan. People needed additional pre-employment checks were completed before new support when accessing the community and staff had clear employees began work. For example Disclosure and guidance to support them. Staff described to us the Barring checks were completed and references were strategies and precautions they operated in order to keep followed up. the person and themselves safe while ensuring the person had a positive experience. As well as formally documented

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Is the service effective?

only way that will work with my son.” The registered Our findings manager and staff talked about people knowledgeably and demonstrated a depth of understanding about people’s The provider had identified where changes to the specific support needs and backgrounds. People had environment were necessary to meet people’s needs. allocated key workers who worked closely with them to However, action had not been taken to meet those help ensure they received consistent care and support. identified needs in a timely manner. At the last inspection in January 2014 we noted the bathroom for one person A relative told us of an occasion when their family member was not meeting their needs. At the time we were told there had become ill. They said the staff member who was with were plans to either relocate or refurbish the bathroom. At them at the time had known: “exactly what to do.” this inspection we found this work had still not been Following the event staff had contacted them by phone to carried out. The bathroom was cramped and the toilet was reassure them. They commented; “They described situated on a raised narrow platform which felt confined. everything that had happened, all the detail. They were This was significant as the person was of large stature. very good.” There was no fitted shower and the person was using a New staff were required to undertake an induction process shower attachment from the taps. The flooring was in a consisting of a mix of training and shadowing and poor condition. The registered manager told us the work observing more experienced staff. The induction process had been planned to be carried out at the beginning of had recently been updated to include the new Care September 2015, 20 months after the last inspection. Certificate. One new member of staff described the However this had been further delayed due to the induction as; “Really, really good. It’s giving me the tools to maintenance team undertaking training. do the job effectively.” Another said the shadow shifts were A relative told us there were plans for their family member particularly important as they; “Help relate the theory to to have a swing in the garden. Before this could be practice.” purchased the ground needed to be flattened as the area Training identified as necessary for the service was was on a slope. They told us this would be of great benefit updated regularly. Staff also had training specific to for the person as they enjoyed being outside and taking people’s needs such as Autism Awareness. Staff told us the part in physical activities. The relative said they understood training was good. One commented; “Spectrum is very this was going ahead; “But seems to be taking a very long good at that.” Another told us the trainers were very good time.” and; “Extremely enthusiastic.” A relative said they found One person had an en-suite bathroom. The extractor fan staff to be competent and trusted them to support their had broken and the registered manager told us this had family member appropriately. been broken for “about three weeks.” The person enjoyed Staff had received training in the Mental Capacity Act (2005) running the shower for long periods of time and the shower and associated Deprivation of Liberty Safeguards (DoLS). had been fitted with a timer to shut the water off to prevent They demonstrated an understanding of the underlying condensation building up. However the timer had stopped principles of the legislation. The MCA provides a legal working and the combined effect of these two problems framework for acting and making decisions on behalf of had resulted in black spots of mould developing on the individuals who lack the mental capacity to make specific bathroom walls and ceiling. decisions for themselves. DoLS provides a process by which This was in breach of Regulation 12 of the Health and a provider must seek authorisation to restrict a person for Social Care Act 2008 (Regulated Activities) Regulations the purposes of care and treatment. There were some 2014. restrictions in place for people and mental capacity assessments and best interest meetings had taken place People were supported by skilled staff with a good and were recorded as required. Meetings had included understanding of their needs. A relative told us they external healthcare representatives, an Independent observed staff to be competent and consistent in their Mental Capacity Advocate (IMCA) and family members to approach. They commented; “The staff are amazing, they help ensure the person’s views were represented. know him inside out. And they all do the same thing, it’s the

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Is the service effective?

Applications for DoLS authorisations had been made to the baking and they both love it.” One person was especially local authority. As these had been made some time ago interested in being involved in activities in the kitchen. The Spectrum had recently contacted the local DoLS team to kitchen layout had been designed to accommodate their ensure the applications were in progress. needs and allow them to be supported effectively and safely. People took part in choosing meals on a weekly basis. Pictures were used to support people to make meaningful People were supported to access health care professionals choices. The range of meals available included recipes as necessary, for example GP’s, opticians and dentists. which took account of people’s cultural background. Staff Where necessary specialists were consulted such as told us the budget for food was good and allowed the Speech and Language therapists and the Intensive Support service to access good local produce and have takeaway team. One person had recently had a change in their health nights and regular meals out. People were supported to be needs and a medicines review had been carried out with involved in preparing meals such as homemade burgers. A the relevant consultant. member of staff commented; “They are both very good at

8 East Wheal Rose Inspection report 04/01/2016 Good –––

Is the service caring?

were decorated to reflect people’s personal tastes and Our findings preferences. Family photographs were on display throughout the building. Communication tools were Staff spoke of the people they supported fondly and with readily available to people within their own living space. enthusiasm for their achievements. One commented; “It’s brilliant to see [person’s name] out, he’s so happy. He’s Care plans guided staff on how to recognise and support done so much and he really enjoys himself.” people when they became distressed or anxious. For example we saw written; “When I am sad I will …make loud Neither of the people living at East Wheal Rose used words vocalisations and a throaty growl noise. Ask [person’s to communicate. Staff were aware of the various methods name] if you can rub his shoulder.” people used in order to communicate and these were also recorded in care plans. A range of tools were used to People were supported to access the local community. One support people such as pictures, choice boards, symbol person sometimes behaved in a way which staff might find strips and basic sign language or Makaton. Makaton is a difficult to manage in the community. There were clear simple sign language system developed for use by people strategies in place to guide staff on how to do this with a learning disability and/or autism. Care plans effectively. The registered manager told us; “We need to contained photographs of the signs people might use. This promote positive experiences in the community.” was important as people had adapted universally Staff recognised the importance of sustaining family recognised signs creating their own version. Symbol strips relationships and worked closely with relatives. Families are visual tools which use a limited amount of photographs visited regularly and staff accompanied people on visits or pictures to help people understand what activities or outside Cornwall to spend time with their families. In events are going to take place over a specific time. One care addition people kept in contact with their relatives using plan stated symbol strips should be used throughout the Skype. day outlining morning, daytime and evening routines. Both people also used objects of reference to indicate choice. People’s privacy was respected. One member of staff For specific situations which people might find difficult to described the routines for one person when bathing. They cope with or understand staff developed social stories to told us they would ask the person two minutes in advance assist them. These are short descriptions of a particular if they could support them with personal care. This allowed situation, event or activity, which include specific the person to process the information and helped ensure information about what to expect in that situation and they did not feel rushed. They would then wait until the why. This demonstrated staff were able to support people’s person gave them the thumbs up sign and made eye communication using a wide range of tools as appropriate. contact with them. They added; “I always ask permission, it’s his space.” The registered manager told us one person We looked round the building which was divided into two would indicate when they wished to spend time alone. distinct flats. Each person had access to a kitchen, Their garden had been made secure to enable them to bathroom and garden area. Bedrooms and living areas spend time there on their own if they wished.

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Is the service responsive?

were identified for winter and summer in order to Our findings accommodate this. Both people enjoyed physical activities. The service had three staff bikes to allow staff to People’s care plans were detailed and informative, accompany people on bike and scooter rides. People also outlining their background, preferences, communication went ice skating and used a local sports hall. Due to and support needs. Where certain routines were important insurance restrictions only staff over the age of 25 were to people these were broken down and clearly described, permitted to drive Spectrum vehicles. Staff told us this so staff were able to support people to complete the meant unless the rota was carefully managed there could routine in the way they wanted. Care plans were regularly be occasions when no driver, or only one driver, was on reviewed. One page profiles had been developed to give shift. This impacted on people’s ability to take part in staff and others a brief description of the person, their likes activities in the community. We discussed this with the and dislikes, what was important to them and how best to registered manager who told us half the staff team were support them. These contained information such as; “I able to drive the vehicles and they tried to organise rotas to need interaction from staff to keep me motivated and ensure driver were always available. focussed.” And; “Give me time to process information.” ‘Micro plans’ were also in place to give staff clear guidance One person enjoyed visiting beaches and bringing sand when supporting people to undertake specific tasks or back to the service. Their key worker had developed a book activities; for example how to support people in a vehicle. containing information about various beaches throughout Staff told us the care plans were useful, particularly as the county. There was information for staff on parking people’s needs were so complex. facilities and cafes and toilets. Nearby walks were described including the length and difficulty. There was There were a range of systems to support communication space to record how successful the trip had been and any within the staff team to help ensure they were up to date learning points. The registered manager told us they with any change in people’s needs. Daily logs were expected the book would be used to widen the person’s completed and a communication book was in place. Staff experiences and encourage staff away from continually used this to record any appointments, relevant phone calls revisiting the same beaches. or other communications to be shared amongst the staff team. A white board in the administration office was used A relative told us their family member went out frequently. to note any information which staff needed to be quickly Staff sent them photographs of the various activities their aware of when coming on shift. Staff told us they were a family member took part in. They appreciated this and close team and effective at sharing information as found it an informative and meaningful way of keeping up necessary. to date with their relatives’ life. People had access to a range of activities and care plans There was a satisfactory complaints procedure in place outlined how to support people to complete them. which gave the details of relevant contacts and outlined the People’s care documentation emphasised the need for time scale within which anyone should have their predictability for people. For example; “An activity rota that complaint responded to. A relative said they had not had gives me consistency should be followed.” The registered reason to complain formally but would approach the manager told us one person found crowds and heat registered manager if they had any concerns. difficult to cope with. Different activities and places to visit

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Is the service well-led?

service. One member of staff told us; “The support from Our findings other staff has been really good. But I was doubting myself and thought I didn’t get the support or feedback I needed Staff reported that they sometimes felt unsupported and to make sure I was doing OK. It couldn’t be helped.” unappreciated by Spectrum. One said; “You don’t always feel valued. You’re just a number that’s replaceable.” There This was in breach of Regulation 17 of the Health and had been a recent proposed change to the pay structure Social Care Act 2008 (Regulated Activities) Regulations meaning staff would not receive an enhanced pay rate for 2014. working weekends. Senior management told us this was There were clear lines of responsibility within the staff due to the complexity of the system and that pay rates team. The registered manager was supported by a would be increased generally to counteract the effect of Developmental Support Worker (DSW). DSW’s are used in this change. There had been a period of consultation in several of Spectrums services to act as a link between the respect of these changes. However staff were sceptical service and Spectrum. Both people living at East Wheal about the value of the consultation. One told us; “No-one Rose had an assigned key worker. A third member of staff will put themselves up for weekends anymore.” supported these roles as a ‘floating’ key worker. Each Staff were confident higher management would respond member of staff had specific responsibilities allocated to appropriately to any concerns regarding people’s safety or them such as overseeing vehicle maintenance and checks possible risk of abuse. However they did not have the same and fire safety audits. confidence that other issues staff might raise would be Staff displayed a shared set of values in their conversations listened to, for example about staffing levels. One with us. There were repeated references to the importance commented; “Concerns are brushed under the carpet by of supporting people to have choices in their everyday head office.” lives. One told us; “It’s all about service user choice. Making The registered manager had been absent from work for sure we’re supporting people to do what they want.” Staff some time over the preceding months and this had were enthusiastic about supporting people. Comments impacted on staff team confidence. Staff said there had included; “I absolutely love it!” been a lack of ownership of the service and their concerns Questionnaires were circulated to families once a year to had been raised with Spectrum head office. In response to gather their views of the service. These had gone out this a divisional manager had recently taken on oversight of recently but no responses had been returned at the time of the service and staff saw this as a positive development. the inspection. People were given an adapted version of One said; “I can ring [divisional manager] with any issues.” the questionnaires to complete once a month. These were Due to the registered managers absence there had been a in easy read format and staff supported people to give yes drop in the level of supervisions in recent months. The or no responses to questions regarding their environment registered manager told us this was being addressed. In and activities for example. Learning logs were completed order to enable them to carry out managerial related tasks as a further means of recording what worked well for such as these, the service’s managers told us they were people. The registered manager told us; “By hook or by allocated six hours administration time per week, “When crook they’ll get their point across.” we’ve got the staff.” They added that as they worked shifts Incidents were recorded appropriately and reviewed they were able to carry out informal observations on a daily monthly in order to identify any trends. Other regular basis and were aware of the day to day workings of the audits covered areas such as medicines, electrical appliances and fire safety.

11 East Wheal Rose Inspection report 04/01/2016 This section is primarily information for the provider

Action we have told the provider to take

The table below shows where legal requirements were not being met and we have asked the provider to send us a report that says what action they are going to take. We did not take formal enforcement action at this stage. We will check that this action is taken by the provider.

Regulated activity Regulation

Accommodation for persons who require nursing or Regulation 15 HSCA (RA) Regulations 2014 Premises and personal care equipment How the regulation was not being met: Premises and equipment were not suitable for the purpose for which they were being used and/or properly maintained. Regulation 15(1)(c)(e)

Regulated activity Regulation

Accommodation for persons who require nursing or Regulation 17 HSCA (RA) Regulations 2014 Good personal care governance How the regulation was not being met: Systems or processes were not operated effectively in order to: Enable the registered person to assess, monitor and improve the quality and the safety of the services provided. Seek and act on feedback from relevant persons for the purposes of continually valuing and improving the service. Reg 17(1)(2)(a)(e)

Regulated activity Regulation

Accommodation for persons who require nursing or Regulation 18 HSCA (RA) Regulations 2014 Staffing personal care How the regulation was not being met: There were not sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed.

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